News & Media

Monday, February 17, 2014

Alcoholism & Drug Abuse Weekly

February 17, 2014

By Alison Knopf

Tri-Cities Holdings, an opioid treatment program (OTP) that has been trying to get a certificate of need in Johnson City, Tennessee, is waiting to hear from the federal Department of Justice (DOJ) about an appeal it filed based on civil rights violations. Represented by attorney James A. Dunlap Jr. from Atlanta, Georgia, the OTP would serve the 500 to 1,000 people who live near Johnson City but have to drive more than 100 miles across the border to North Carolina to obtain their medication.

The complaint is asking the federal Department of Justice to intervene in the case of Tri-Cities Holdings and eight patients, who have the disability of opioid addiction. The OTP says that the certificate of need process instituted by the state and the ordinances imposed by the city violate the Americans with Disabilities Act (ADA).

Lisa Taylor, an attorney with the DOJ Civil Rights Division in Washington, has been investigating the case, which began in June 2013. The violations, according to Dunlap, have gone on for more than a decade, resulting in lost lives.

"It’s unconscionable that a state would have in place a certificate of need process that would force a pregnant opioid-dependent woman to drive one to two hours each way every day to receive what is known and accepted as the standard of care for her medical condition.”Zac Talbott

An OTP in Johnson City would be the only clinic within 50 miles in any direction. However, Johnson City and the state Health Services and Development Agency (HSDA), which issues certificates of need, have made it difficult to site the clinic. Since 2003, Johnson City has used a zoning ordinance to block the OTP, according to Dunlap.

High need

Ironically, Johnson City and the surrounding area have many people with opioid addiction who need treatment. Currently, they drive — often over dangerous mountain roads in the early-morning dark so they can get to work on time — across the border.

“It’s unconscionable that a state would have in place a certificate of need process that would force a pregnant opioid-dependent woman to drive one to two hours each way every day to receive what is known and accepted as the standard of care for her medical condition,” said Zac Talbott, the director of the Tennessee Statewide and Northwestern Georgia chapter of the National Alliance for Medication Assisted Recovery (NAMA Recovery). “The certificate of need process in Tennessee blatantly discriminates against opioid-dependent individuals, as no other substance use disorder treatment other than opioid treatment programs is subjected to the certificate of need process in Tennessee.”

Talbott told ADAW that he hopes the DOJ will rule, as a result of their investigation, that the certificate of need process in Tennessee and the Johnson City ordinances violate the ADA. “The current certificate of need process in the state of Tennessee is, quite literally, killing people,” he said. “This process has resulted in the blocking of numerous opioid treatment programs from opening over the years.”

“NAMA Recovery of Tennessee will continue to advocate for opioid-dependent individuals — both those in treatment and those who are still unable to access the gold standard treatment due to the state’s discrimination — until quality opioid agonist therapy is available on demand for every person who needs it,” Talbott said.

Criticism from NC provider

And Jana Burson, M.D., a North Carolina internist who treats opioid addiction with buprenorphine and also works in an OTP, said medication-assisted treatment of opioid addiction with methadone “is one of the most evidence-based treatments in all of medicine, yet government officials in Tennessee have repeatedly interfered with the delivery of this essential treatment to its citizens.”

Noting that Tennessee has a high rate of overdose deaths, Burson said, “You’d think they would welcome help to treat opioid-addicted citizens instead of thwarting efforts to establish an opioid treatment program.”

Johnson City and other towns of Eastern Tennessee rewrote their zoning laws in an effort to prevent methadone clinics from being established, said Burson. Even though Johnson City’s attorney said there was no intentional discrimination against drug addicts, “history speaks for itself,” said Burson. “Multiple facilities have tried and failed to get permission for a methadone clinic in that town over the last ten years,” she said. Future generations will likely judge state and local officials harshly for preventing the treatment of opioid addiction with methadone, since this treatment has been proven to save lives, she said.

Word was expected from the Justice Department on the results of its investigations shortly.

Bottom Line…

The state of Tennessee and a city are charged with violating the civil rights of patients in opioid treatment with methadone.

Wednesday, January 15, 2014

“This week, 76 organizations and experts in maternal, fetal, and child health, addiction treatment, and health advocacy filed an amicus curiae (friend of the court) brief before the New Jersey Supreme Court, urging it to overturn a lower court ruling making the state’s civil child abuse law applicable to women who received medically prescribed methadone treatment while pregnant.

At the center of the case is a woman, identified by the court as Y.N., who had been struggling with a dependency on opioid painkillers. When she found out she was pregnant, she followed medical advice and obtained care that included methadone treatment. She gave birth to a healthy baby who was successfully treated for symptoms of neonatal abstinence syndrome (NAS). NAS is a side effect of methadone treatment and other medications, such as those commonly prescribed to treat depression. Y.N. was reported to the Division of Child Protection and Permanency (DCPP, formerly the Division of Youth and Family Services), and was judged to have abused or neglected her child because she agreed with her physician’s recommendation and followed the prescribed course of methadone treatment while pregnant.

Lawrence S. Lustberg of Gibbons P.C., co-counsel for the amici, explains that “the New Jersey Supreme Court has been a national leader in recognizing that when cases raise scientific, medical, or other technical issues, the evaluation of these issues must be informed by existing scientific knowledge, including expert testimony.” He added, “This case should not be an exception, yet, the decision in the lower court was reached without the input of a single medical expert and without considering the established science addressing the value of methadone treatment to maternal, fetal, and child health, and other key health and social welfare issues in the case.”

Dr. Robert Newman, one of the experts represented in the brief and a nationally and internationally recognized authority on methadone treatment, said, “As a matter of medicine and health care, it is simply nonsensical to regard methadone treatment as a form of child abuse.” He explained, “Decades of research unequivocally demonstrate the benefits of treating a pregnant woman’s addiction to opioids with methadone, an extraordinarily well-studied medication whose benefits to the mother as well as the baby unquestionably outweigh the treatable and transitory side effects that are sometimes seen in the newborns.” He noted that “It is not recommended that women simply stop using opiates during pregnancy” and that “methadone and other related treatments are acknowledged by national and international governmental, academic and clinic authorities to be the best choice for maternal, fetal, and child health, reducing risks of miscarriage, stillbirth, and premature birth.”

The experts’ brief addresses the fact that the lower court did not consider health measures that can be taken after birth to reduce symptoms of NAS, including keeping the new mother and baby together and encouraging breast feeding. The brief also notes that there is nothing in the lower court’s decision that limits its ruling to pregnant women who receive methadone treatment and could be applied to any pregnant woman, including those who experience health conditions such as epilepsy, depression, and blood clots that require medication that have potential adverse effects in the newborn.

Lynn Paltrow, Executive Director of National Advocates for Pregnant Women and co-counsel representing the experts, explained that, “unless the lower court decision is reversed, New Jersey would become the only state in the U.S. to effectively ban pregnant women from receiving methadone treatment.” She added, “DCPP’s position and the lower court’s decision is inexplicable and irrational. They not only fly in the face of the recommendations of the World Health Organization and the U.S. government, but New Jersey itself, which, through collaborations between the New Jersey Department of Mental Health and Addiction Services and DCPP, provides methadone treatment to pregnant women and families in the child welfare system.”

The court is expected to hear oral arguments this term. The group of expert amici included the American College of Obstetricians and Gynecologists, American Psychiatric Association, American Public Health Association, American Society of Addiction Medicine, Medical Society of New Jersey, New Jersey Psychiatric Association, New Jersey Obstetrical and Gynecological Society, National Council on Alcoholism and Drug Dependence, and National Council on Alcoholism and Drug Dependence-NJ. A full list of amici is available Here.

In 2013, more than 50 national and international experts published an open letter urging that media coverage of prenatal exposure to opioids be based on science, not stigma and misinformation. This letter is available Here.

Friday, November 15, 2013

The NIMBY (Not In My Back Yard) syndrome is one significant challenge for opioid treatment programs (OTPs), which can’t operate if they can’t get approval from municipalities. Methadone maintenance treatment has been proven effective and producing good outcomes for five decades, but that isn’t preventing politicians from pandering to prejudice and discrimination. Still, the field is forging ahead, opening new programs and providing access to treatment to needy patients.

Sally Friedman, legal director with the Legal Action Center, said that local authorities often try to zone out drug and alcohol programs in general, but it’s even more difficult to site a methadone program. “It’s challenging to site any type of facility that serves people who folks don’t want around,” she said. “I’ve seen this from examining case law—there’s NIMBY for everything, the elderly, group homes, communities want to keep out all types of social services.”

But a special place in NIMBY-land is reserved for OTPs. In 1977 the Legal Action Center won a landmark discrimination case in which a federal court prevented White Plains in New York from zoning out alcohol and drug abuse treatment programs—and while it wasn’t specific to OTPs, OTPs are included. “Stereotypes and myths” play a part in the NIMBY decisions, said Ms. Friedman.
The Americans with Disabilities Act (ADA) clearly supports OTPs and their patients, and municipalities and their lawyers can easily lose in federal court since the law is so clear. “But there’s a lot of political calculation,” said Ms. Friedman. Local politicians think they have more to gain politically from keeping the facility out, so they’re willing to risk the lawsuit and let the court tell them what they have to do.MAT First

One point that the substance abuse treatment field in general needs to make more strongly is that medication is the first-line evidence-supported treatment for opioid addiction. “Myth and misunderstanding continue to plague not just methadone alone but medication-assisted treatment [MAT] in general,” said Michal Botticelli, deputy director of the White House Office of National Drug Control Policy [ONDCP]. For opioid dependence in particular, medication is the “first line in our arsenal,” he said. “We have to make sure people understand that this is the standard of care.”
Mr. Botticelli added that there is an opportunity to create a greater consumer voice in favor of MAT. “People have done exceedingly well on methadone maintenance.” Some people need more than medication—other social supports and the structure of an OTP—but others don’t.

As states continue to express concern about prescription drug abuse and overdoses, mainly surrounding opioids, the ONDCP is increasing its stress on the importance of access to methadone and buprenorphine, as well as social supports provided in an OTP. “If we really want to deal with overdose deaths, we need to make sure that we have adequate access to MAT.”

The same myths and stereotypes that bolster NIMBY apply to the criminal justice system, which routinely denies access to medication-assisted treatment. The biggest myth is the one that methadone and buprenorphine are “substituting one addiction for another,” which couldn’t be farther from the truth. Patients in MAT are not addicted—they are not pursuing drugs, they are in recovery, employed, productive members of society. But proponents of discrimination don’t understand how the medications work.Lack of Negative Impact

It’s also easy to demonstrate the lack of a negative impact in NIMBY siting cases. Jerry Rhodes, chief operating officer of CRC Health Group, said it’s important to bring out studies that show crime goes down when clinics are deployed. “There is science that shows methadone treatment has good results,” he said. But here’s the problem: the issue is an emotional, not a logical, one.

The studies showing that methadone works have been ignored by many public policy makers. And while OTPs had been hoping to enlist government officials and regulators in support of MAT, that isn’t working either. “We’ve had the rug pulled out from under us,” said Mr. Rhodes. “We’re trying to get a more robust commitment.”Support From Patients

One thing OTPs could do better is to involve the support of patients, said Mr. Rhodes. “There are often compelling personal stories around the need for treatment, and the effectiveness of MAT.”
In general, the OTP field has done a poor job of rallying patients. But Mr. Rhodes understands that it’s hard to get patients to come forward. “You could lose your job, your neighbor could say something, there’s a fear of being seen as a patient in a clinic.”

The field is beginning to recognize that OTP patients, like other people in recovery, can be a significant voting bloc. For example, there are 5,000 to 6,000 OTP patients in West Virginia. In a small state like West Virginia, 5,000 votes—in some places, even 1,000 votes—can swing an election. When there is no access to MAT, patients—and prospective patients, who also vote—suffer.
“This is a job for the National Alliance for Medication Assisted Recovery (NAMA),” Mr. Rhodes said.Collaboration

Another good advocacy tactic involves collaborating with other groups. Mr. Rhodes cited the effectiveness of the autism advocacy movement, which is spearheaded by parents who are fierce advocates for their children. Drug addicts, alcoholics, people with mental illness need the same kind of advocates, but have always been treated as marginal populations, which is what drives the stigma. “We can do a better job of working with other constituents,” he said.
Even as a field, various types of treatment are fragmented—medication, no medication, alcohol, drugs—and OTPs could benefit by these groups working together and bringing OTPs into the tent.Back to NIMBY

The bottom line is, OTPs need facilities, and that means they need certificates of occupancy. Mr. Rhodes warns clinics against going into a community to develop a clinic and not garnering support first. “You can’t do this and not deal with NIMBY, but you can do a better job of trying to support these efforts.”

Here are some of the things you can expect to hear when you try to site a program. “This isn’t our problem.” That’s pretty easy to refute, because an OTP usually has done research and knows that there is an opioid problem. For example, at one meeting, someone stood up and said, “I don’t want this town becoming a methadone mecca.” A physician who was there then said, “You don’t understand, this town is already a heroin mecca.”The OD Bandwagon

Despite the many newspaper articles about prescription opioid abuse and overdoses, there are rarely any discussions of the cure—treatment. “People don’t understand how prescription opioid abuse relates to methadone treatment,” said Mr. Rhodes. “We rarely address the cure, we just talk about the magnitude of the problem.”

“Education is key,” agreed Ms. Friedman. “We need to explain how the disease works, how the treatments work, and how we produce successful outcomes.”

Tuesday, November 05, 2013

The Illinois Medicaid program is weighing whether to
resume covering methadone treatments, a proposal that is likely to stir up
controversy after the practice was halted about 20 years ago amid criticism
about the soaring costs of substance abuse care.

Restarting the coverage of treatment
for heroin addicts is among several recommendations contained in a Sept. 27 reportto Gov. Pat Quinn by the Illinois Department of Healthcare and Family
Services, which runs the state's Medicaid program, and the state Department of
Human Services. The report addresses the impact on inpatient hospital detox
services of the so-called Smart Act, a $2.7 billion package of budget cuts and tax increases passed in 2012 intended
to help the struggling Medicaid program stay afloat.

Illinois Department of Healthcare and Family
Services. Report on the Detoxification Services Planning Process and Resulting
Recommendations as per the Save Medicaid Access and Resources Together (SMART)
Act. Senate Bill 2840- Public Law 97- 0689. September 27, 2013.

Friday, November 01, 2013

In 2012, under contract with the Philadelphia Department of Behavioral Health and Intellectual disAbility Services (DBHIDS), and with additional support from Community Care Behavioral Health Organization (Community Care), the Institute for Research, Education and Training in Addictions (IRETA) conducted a project to determine best practice guidelines for the management of benzodiazepines in medication-assisted treatment (MAT). The project was conceived in response to frequent benzodiazepine use among individuals in MAT and a relative absence of research -based guidance on clinically effective treatment strategies for managing their use. Designed to be a resource for clinicians, these guidelines aim to distinguish areas of scientific/clinical consensus and areas where that does not exist. They are not intended to dictate clinical practice.

This report details the development of the project, methods, results and the final list of practice guidelines. IRETA utilized the RAND/UCLA Appropriateness Method to determine appropriate guideline statements based on the research and clinical experience of a panel of experts in the field. The two-round rating process and half-day expert panel meeting yielded 225 guideline statements, which IRETA distilled into a shorter list of guidelines for practitioners to use in real-world clinical settings.

Recommendations from the expert panel members include:

CNS depressant use is not an absolute contraindication for the use of either methadone or buprenorphine in MAT, but is a reason for caution because of potential respiratory depression. Serious overdose and death may occur if MAT is administered in conjunction with benzodiazepines, sedatives, tranquilizers, antidepressants, or alcohol.

Individuals who use benzodiazepines, even if used as a part of long-term therapy, should be considered at risk for adverse drug reactions including overdose and death.

Many people presenting to services have an extensive history of multiple substance dependence and all substance abuse, including benzodiazepines, should be actively addressed in treatment.

MAT should not generally be discontinued for persistent benzodiazepine abuse, but requires the implementation of risk management strategies.

Clinicians should ensure that every step of decision-making is clearly documented.

During the half-day meeting in September 2012, expert panelists added an additional guideline statement: “Clinicians would benefit from the development of a toolkit about the management of benzodiazepines in methadone treatment that includes videos and written materials for individuals in MAT.” This recommendation is consistent with the overarching theme of patient education, which was discussed lengthily at the project’s Kickoff Conference in February 2012 and emerged as a significant issue in the final practice guidelines.

Tuesday, October 22, 2013

LONDON (Reuters) - Reckitt Benckiser may sell its pharmaceuticals unit, which has been suffering
from declining sales of its main heroin addiction drug, to focus on growing
consumer health and household cleaning products businesses.

The British consumer goods group
said on Tuesday it was reviewing options for the pharmaceuticals business,
which analysts said could fetch over 2 billion pounds ($3.2 billion) and appeal
to international drugmakers.

Tuesday, October 01, 2013

Methadone
is an inexpensive medication approved by the U.S. Food and Drug Administration
for the treatment of heroin and other opioid dependence. Studies indicate that
methadone reduces relapse, emergency department visits and hospital admissions.
In general, the stability methadone provides helps patients better manage their
overall health.

Including
methadone treatment in Illinois’ State Medicaid Plan will reduce healthcare
costs and help the state address the growing epidemic of opioid dependence.
Patients can only access methadone treatment for their opioid dependence
through the highly regulated Opioid Treatment Program (OTP) system. The system
requires programs be registered with the Drug Enforcement Administration,
certified by the federal Health and Human Services’ Center for Substance Abuse
Treatment and licensed by the Illinois Department of Human Services’ Division
of Alcoholism and Substance Abuse.

OTPs
utilize a multidisciplinary team comprised of physicians, nurses, and
counselors to address the bio-psycho-social needs of each individual patient.
This holistic approach to treatment has been in place in OTPs for more than 40
years, long before most other systems embraced the health home model. The
strong positive relationships between patients and professionals in OTPs helps
patients feel empowered to address their own health needs.

Numerous
studies have documented the cost savings generated by stabilizing opioid
dependent individuals on methadone and helping them manage their comorbid
conditions. Emergency department visits and hospital admissions are
significantly reduced because patient health is carefully monitored and
addressed. In spite of medical evidence documenting the effectiveness of
methadone treatment and the cost savings achieved, some health plans have
excluded this treatment modality. Patient advocates have suggested this is
largely due to the stigma related to heroin addiction.

Untreated
opioid dependence in Illinois leads to unnecessary emergency department visits
and hospital admissions. Some of these visits are due to drug overdoses or
attempts to seek treatment for withdrawal symptoms. However, others are due to
the multiple unmanaged comorbid conditions, such as diabetes and hypertension,
which are highly prevalent in opioid dependent individuals.

Illinois’ administrative leadership has demonstrated its
commitment to resolving Illinois’ fiscal crisis. The cost savings achieved by
covering methadone treatment in Illinois’ State Medicaid Plan can be part of
this solution. In addition to saving taxpayer dollars in unnecessary
hospitalizations, providing increased access to treatment aligns with three
core objectives of Illinois’ Budgeting for Results initiative: 1) to improve
the overall health of Illinois residents; 2) to meet the needs /improve the
quality of life for the most vulnerable persons; and 3) to increase individual
and family self-sufficiency.